An Enhanced Recovery after Surgery Pathway for Microvascular Breast Reconstruction Is Safe and Effective.

BACKGROUND: The aim of this study was to develop, implement, and evaluate a standardized perioperative enhanced recovery after surgery (ERAS) clinical care pathway in microsurgical abdominal-based breast reconstruction. METHODS: Development of a clinical care pathway was informed by the latest ERAS guideline for breast reconstruction. Key features included shortened preoperative fasting, judicious fluids, multimodal analgesics, early oral nutrition, early Foley catheter removal, and early ambulation. There were 3 groups of women in this cohort study: (1) traditional historical control; (2) transition group with partial implementation; and (3) ERAS. Narcotic use, patient-reported pain scores, antiemetic use, time to regular diet, time to first walk, hospital length of stay, and 30-day postoperative complications were compared between the groups. RESULTS: After implementation of the pathway, the use of parenteral narcotics was reduced by 88% (traditional, 112 mg; transition, 58 mg; ERAS, 13 mg; P < 0.0001), with no consequent increase in patient-reported pain. Patients in the ERAS cohort used less antiemetics (7.0, 5.3, 2.2 doses, P < 0.0001), returned to normal diet 19 hours earlier (46, 39, 27 hours, P < 0.0001), and walked 25 hours sooner (75, 70, 50 hours, P < 0.0001). Overall, hospital length of stay was reduced by 2 days in the ERAS cohort (6.6, 5.6, 4.8 days, P < 0.0001), without an increase in rates of major complications (9.5%, 10.1%, 8.3%, P = 0.9). CONCLUSIONS: A clinical care pathway in microsurgical breast reconstruction using the ERAS Society guideline promotes successful early recovery.

A standardized operative team for major head and neck cancer ablation and reconstruction.

BACKGROUND: Prolonged procedure time in head and neck cancer ablation and free flap reconstruction cases has been shown to significantly increase perioperative complications. The authors' objective was to evaluate the effectiveness of a standardized surgical nursing team for head and neck cancer ablation and free flap reconstruction operations for reducing procedure time. METHODS: A retrospective cohort analysis of consecutive patients presenting for head and neck cancer ablation and free flap reconstruction between January 1, 2007, and September 1, 2010, was performed. A standardized head and neck surgical nursing team was introduced on May 1, 2009, at our center. Procedure time and case time were measured before and after the introduction of the team. Univariable analyses were performed to evaluate the difference in procedure and case time between the two cohorts. A multivariable linear regression model was developed to control for confounding variables. RESULTS: There were 52 cases before the team was introduced and 49 cases after. Mean procedure time was reduced by 47.1 minutes (p = 0.04) and mean case time was reduced by 68.9 minutes (p = 0.01) after team introduction. The multivariable linear regression analysis demonstrated a significant reduction in operative time after team introduction, controlling for confounding variables. CONCLUSIONS: The introduction of a standardized surgical nursing team led to a significant reduction in procedure and case time. A standardized team approach improves operating room efficiency in complex cases such as free flap reconstruction following tumor ablation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.